UWorld #1

Who is hep A vaccine recommended for?

-men who have sex w/men -travelers to countries where its endemic -chronic liver dz

What are the possible complications of PBC?

-severe hyperlipidemia (xanthelasma) -malabsorption -metabolic bone disease (osteoporosis, osteomalacia) -hepatocellular carcinoma

What does the dx of acute liver failure require?

1) elevated aminotransferases 2) signs of hepatic encephalopathy 3) impaired hepatic synthetic function (INR>1.5)

What is Shy Dragar syndrome?

1) parkinsonism 2) autonomic dysfunction 3) widespread neuro signs

19 yo college student w/multiple sexual partners, painful lesions on R hand. Feels feverish and tired. Organism?

HSV -multiple sex partners and painful, vesicular hand rash suggest *herpetic whitlow* -mild prodrome (fever, malaise) and then grouped vesicles on erythematous base

Felty syndrome

RA, neutropenia, splenomegaly

22yo F w/HA for last 6 wks. Pulsatile in quality and assoc w/nausea. BMI 33. LP had elevated opening pressure. Next step?

acetazolamide -IIH (pseudotumor cerebri) -acetazolamide is 1st line, inhibits choroid plexus carbonic anhydrase by decreasing CSF production

72 yo man w/severe fatigue. Firm, enlarged cervical inguinal and supraclavicular LNs. Soft II/VI grade systolic murmur along left sternal border. Abdomen soft and nontender. Liver span 10cm, spleen palpable. Cause of anemia?

bone marrow infiltration -most likely has lymphoma -3 categories: decreased RBC production, increased RBC destruction, and blood loss

Pt comes to dr for routine follow up. HTN, DM, secondary hyperparathyroidism, ESRD. Has carotid bruit. If pt dies within the next 5 yrs, what is most likely cause?

cardiovascular disease -MCC of death in dialysis pts -20% of these deaths due to AMI, 60% are sudden cardiac deaths

64 yo M w/hx of HTN, DM, generalized malaise and palpitations. Irreg irreg rhythm w/narrow complex tachycardia, and no organized P waves. What to give for management?

diltiazem -afib w/RVR -management of new onset afib is assess rate vs rhythm control and prevent systemic embolization -if hemodynamically unstable, then emergency cardioversion -rate control should be attempted initially with B blockers or CCBs

Foreign body sensation in right eye, photophobia, excessive lacrimation. Next step?

fluorescein exam -high velocity injury has greater probability of globe penetration and intraocular foreign body formation -fluoresceine application following Wood's lamp or slit lamp is reasonable next step

What are the risk factors for splenic abscess?

hematogenous spread, immunosuppression, IV drug use, hemoglobinopathies, *infective endocarditis*

64yo M w/2 days of fever, chills, productive cough, L sided pleuritic chest pain. O2 sat is 94% on R side but drops to 89% when he lies on L. Dullness to percussion and bronchial breath sounds on L side. Pathophys?

intrapulmonary shunting -acute pneumonia, hypoxemia due to pulm shunting and V/Q mismatch

Septic shock and AST/ALT elevations 1 day later?

ischemic hepatic injury -liver enzymes usually return in normal within a few wks

66 yo man f/u for HTN. BP 165/95. Has DM2 and HLD, underwent stent placement for PVD 2 yrs ago. CT angio shows 80% atherosclerotic narrowing of R renal artery

lisinopril -renal artery stenosis is common finding in older pts w/high prevalence in those w/severe HTN or PVD -resistant HTN, diffuse athero -Rx: aggressive risk factor reduction (aspirin, optimal DM, HLD, smoking), *if HTN, manage w/ACE or ARB*

65yo M w/4mth hx of periodic back pain radiating to butt and thighs. Pain exacerbated by wlakign or prolonged standing, although he can tolerate bicycling. Cause?

lumbar spinal stenosis -usually seen w/degenerative arthritis w/osteophyte formation affecting facet joints (spondylosis) -neurogenic claudication -"shopping cart sign"

32 yo w/progressive ascending paralysis over the last 12 hrs. More pronounced in L leg. No reflexes in L, 1+ in R. No abnormalities in CSF. Next step?

meticulous search for a tick -progressive ascending weakness over *hours* -more pronounced in 1 leg or arm

What's the most common nephrotic syndrome in pts w/Hodgkins?

minimal change disease

50 yo w/skin rash, jt pains, malaise, fatigue. Hx of IV drug abuse. BP 140/90. Exam shows palpable purpura and hepatosplenomegaly. UA shows hematuria, RBC casts, and proteinuria. HCV positive

mixed essential cryoglobulinemia -common presentation is palpable purpura, glomerulonephritis, nonspecific systemic sx, arthralgias, hepatosplenomegaly, peripheral neuropathy, hypocomplementemia -most pts have hep C

38 yo woman w/progressive muscle weakness, difficult to climb stairs and comb her hair. Has facial hirsutism and mild proximal muscle weakness of the extremities. What is responsible for weakness?

muscle atrophy -painless muscle weakness assoc w/wt gain, bone loss, HTN, hirsutism consistent w/hypercortisolism *Cushing syndrome* -myopathy in Cushing's due to direct catabolic effects of cortisol on skeletal muscle (muscle atrophy)

Post nasal cough. Takes chlorphenriamine improves sx. Decrease in what is responsible for sx relief?

nasal secretions -eliminates nasal discharge b/c H1 antag

51yo has difficulty walking and R sided foot pain. PMH has DM1, HTN, HLD. Xray shows effusions in severe trasometatarsal jts, large osteophytes, extra-articular bone fragments. Cause?

nerve damage -*Charcot joint* due to DM -decreased proprioception, pain, temp due to DM or tabes dorsalis -rx: treat underlying dz, provide mechanical devices to assist in wt bearing

60 yo from Russia w/dizziness, fatigue, wt loss. R upper lobe cavitary lesion. What acid base disturbance?

normal anion gap metabolic acidosis -likely TB, common extrapulm sites include liver, spleen, kidney, bone, adrenals -common cause of chronic primary adrenal insuff -pt has hyperkalemia, hypoglycemia, eosinophilia -primary adrenal insuff (addison's) is characterized by decreased cortisol, adrenal sex hormone, aldosterone secretion

What is EBV DNA in the CSF specific for?

primary CNS lymphoma

On chemo, now has anorexia. What is best pharm agent?

progesterone analog -megestrol or medroxyprogesterol acetate and corticosteroids increase appetite and wt gain

What is the foci that usually causes afib?

pulm veins

What rx of hyperthyroidism is likely to worsen pt's eye dz?

radioactive iodine -can raise antibody titers and worsen ophthalmopathy

What characterizes alcoholic hepatitis?

ratio of AST/ALT >2 (mildly elevated <500), elevated GGT, elevated ferritin

20yo man w/1 day hx of fever, HA, AMS. Put on acyclovir. But now Cr 2.8, BUN 38. Cause of AKI?

renal tubular obstruction -crystal induced kidney injury due to IV acyclovir -drug has low solubility -admin IV fluids concurrently

53 yo w/systemic sclerosis. Hb 6.9, Tbili 2.2, Cr 3.8. What is seen on peripheral smear?

schistocytes -scleroderma renal crisis -increased vascular permeability, activation of coag cascade, increased renin secretion

36 yo w/fatigue and weakness. Ca 7.8. PTH 110. Next step?

serum 25-hydroxy vitamin D level -hypocalcemia with high PTH seen in vit D deficiency and CKD

What is epitrochlear LAD characteristic of?

syphilis

1st step for pleural effusion?

thoracentesis